R 3351 (2) PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R— 335
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS RBUILDING USE
2 ``91t�t,Ce� 1 "� RESIDENTIAL �MMERCIAL OTHER-
S /� s
NAME `7" v C ` ) • HAZARDOUS yrs ROOF
FIRE AREA CLASS
COVERING
ADDRESS_ {- u9�hl SA'D✓ EXISTING ROOF COVERING
PHONE Z52-- 7 G NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�" TO BE REMOVED TO BE RETAINED
NAME /� - pin A) TYPE OF ROOF COVERING
ADDRESS, "2G�7 C1 aq. PeAy A - -
RE
CITV&ZIP _ J l 'U/l' / ,1 / T 5 EXISTING
PHONE 7� -YoS �J BUILT-UP ROOF
LICENSE .j O � ASPHALT SHINGLES
NUMBER _
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm the,1 em licensed under provisions of Chapter 9 fcommom '
ling with Be., 7000) of Division 8 of me Business and Prq+•..;on, Coda, WOOD SHINGLES
nd my license a In full force and enact.
License Class Lic.Number.
Data Contractor - OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
hereby'affix [net em exempt from the contractor's Lice... Law for '
me following rano (asps 7oDts, B.aat end?m+es+iont code: An,ary PROPOSED
Or County which req 'res a permit t0 construct,.elter, improve, demolish,Or
Sipe;.env structure.P r ro <,issuance,also Jequl.es the applicant tor such BUILT-UP R00
Ps to file a signed at accent That he is 1.c,nsed pursuant to the provisions
of the Contractor'$ Licans Lew (Cneptar 91(commencing with Section 7000)
o+ Division 0 of the Business d Pro+nsio(s Code).1 that he is exempt In.,. ASPHALT LE$
from and the basic for the a epee exemption. Any violation of Section'
7081.5 by any apPli[dnt for e p ;t subjects the ePpliC Sint[O a Civil Penalty ^�
i .f not mon that five hundred Bolla "ISSEDI.I: WOOD SHAKES
❑ I,
as owner Of the prppariG. o V employe•a with wages as Meir sole
comp•nuti.n.will do the wo�K, and m true to r.is not intended or offered
for fele IBec. )044, BusinasYentl Pr.falai. cads: The Contractor:uc.nsa WOOD SHINGLES
Lew does not apply 10 6wner of property 0 build$Or improves 11h.o.n,
and Who tlan such .rt f.,S.14 Or through his O mployeet,provided that
eucn improvements a e not inunded .r offend + e sale. I/, however, the OTHER (SPECIFY)
uuding or improve ant is told w;N in o e year of c plb,im, the owner
budder Will have t e burden .f proving that he did not b {Id Or improve for
purpose of sale.) PROVIDE I.C.B.O. REPORT NO.
1, as Ow •f Of the property, em exclusively Contracting with licensed
contractors t nstruct the project (Sec. 7044, Business and Professions
Code: The .ni�acl.r, u[.naeLaw does not apply toan.Wn•rmProperty pROVIDEMFGR. INSTALLATIONSPECS.
who builds or improves mer•unand-no conIXrn; for such Projects With a
contractor( 1 licensed pursuant to, In.Contractor's License L.W.
❑ I em exempt under Sec.ason ,8.&Poco 1.r this
owner oats APPLICAT;DATE ,VALUATION PERMIT FEE
WORKS t I have P car,if ON DECLARATION /j/re{1 tereby orkers that have a caftificate Of consent t0se insure,Or a car' (A(,6ititicate of Workeri Compensation Insurances o ecert'I d Ry (Sac ' A00, Lab, ,Policy N.. X11qv iompanv- - SEISMIC
Cortilied copy . b furnished. ve 1C r[me Pilcity inspecuos eivi+ion aEP e9APPlicant VCER A OF E%EMPTI N FROM WORKERS' /s( ,BEFjMIT VALCOMPENSATI I URANCE V(This.action need of be comp) ad f the permit is for one hundred doh
lark($100)or less.)
I certif that in the pert Once of the work for Which this permit
;'sued,
1 shall t employ an person any manner an as to become subject
to the Wo kali pan.ati0 Laws cf�C f.raie.
Oats - APP cant I -oII
NOT" TO APPLIC T: if,
aft;'
s Certificate of Exemption,You should become sub) to the Workers' Compensation Provisions of the
Labor Coda, ade mutt for Th comply with such proy;amns..,his permit All types of roof shall be inspected prior to any root being installed.To
shall be deemed revoked.
certify that I nova a a this Prcaran and lute ma me above;nf.,ma. receive a final am aware there will be three approved inspections:
tion is correct. I agree o compl with an city and county ordinances and Pre, inpr ess, and final. If ro is applied without first obtaining an
,tate law. nlamg ,o b. mug .Poet cti.n, and hereby authorize rapres.n. inspe Ion I Fee I will rem. a n material for inspection.
tetives of this city to an upon the ova mentioned property for .or
I
PurP,a..
(Wel agree to leve, ndemnify and keep harmless the City of Cupertino
against liabilities,jutlg ills,costs and expanses which may in any way accrue
against said City in cons quence of the granting of this permit. _
SIGNATURE OF APPL ANT DATE
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FI AL SPECTION
INSPECTIONS INSPECTOR DATE_ INSPECTOR DATE INSPECTOR DATE_
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY /
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